IF YOU NEEDED SURGERY, WHAT WOULD YOU WANT?
A lower complication rate?
A faster recovery time?
A modern 21st century technique?
Keyhole surgery offers all this,
and that's why we choose it over old-style open surgery for bitch spays
WHAT WOULD YOUR PET WANT?
What is Laparoscopy?
Laparoscopy is a way to explore the organs of your pet’s abdomen using only tiny key-hole incisions.
Using these incisions (generally 1cm), we can insert a camera and our surgical instruments to perform surgery.
Laparoscopy is a safer method of surgery because everything is done under direct magnified visualization.
Organs, such as your pet’s ovaries, do not need to be pulled out of the body to allow the surgery to be performed, so there is less trauma to the internal structures of your pet’s abdomen.
Recent studies have shown the use of laparoscopy to be a less traumatic and a less painful alternative.
With old-style spays, a 5-7cm incision is made in the abdominal wall.
The ovaries are then blindly hooked and the ovarian ligament is torn from the body wall.
This tearing causes pain and can cause bruising. In traditional spays, most vets also unnecessarily remove the uterus.
Due to the location of the uterus and the attempt to minimize the surgical incision, significant tension is placed on the body of the uterus which may cause trauma and bleeding.
Keyhole / laparoscopic spays
This is a minimally-invasive spay that removes the ovaries from healthy dogs and has been shown to be a less painful alternative to traditional spays.
With this technique, 2 small key-hole incisions are made into the abdomen and our laparoscopic equipment is used to perform the surgery.
The ovarian ligament is not torn from the body, but carefully cut and cauterized with virtually no bleeding or pain. No tension is placed on the uterus (which is not removed).
Because of the enhanced visualization, there is less of a chance of leaving ovarian tissue behind.
Laparoscopic spays have been shown to reduce pain levels by two-thirds compared to traditional spays which means a faster recovery and less trauma to their body.
Laparoscopic spays have been found to be two-thirds less painful compared to traditional open spays.
The entire surgery is performed through two tiny incisions (generally 1cm). Smaller incisions are less painful, reduce recovery time, and are less likely to have major post-operative complications.
We have a greatly magnified view of internal organs, allowing for precise cauterized incisions with none of the tearing or bruising normally associated with traditional spays.
Overall, minimally invasive surgical techniques result in safer, visual surgery, with less pain, and excellent outcomes.
Frequently Asked Questions
Q: Will my pet need an Elizabethan collar (E-collar, cone of shame, lampshade, etc) after the procedure?
A: No - at Chertsey Vets, we use Lycra medical pet T-shirts; even though the incisions are tiny, it is still an incision.
If your pet licks at this small incision it could still become infected and require at minimum antibiotics and at worst a second surgery.
However, we find that pets are generally less interested in these incisions (most likely due to the reduced pain) than the larger incisions from old-style spays.
All incisions, regardless of their size, require a minimum of 7 days to heal, so plan on having your pet wear the T-shirt for a minimum of 7 days.
Q: Is it dangerous to not remove the uterus? Why does my vet remove the uterus?
A: Traditionally in the UK, vets have removed both the ovaries and the uterus when performing a spay.
However, there is no benefit in removing the uterus of a young, otherwise healthy animal.
The initial justification came from a belief that it would prevent gynaecological problems later in the dog’s life.
Many papers have since been published debunking this rationale, backed up by data from other European vets who only remove the ovaries.
Hopefully even if UK vets don’t perform laparoscopic spays, they will start at the very least to perform ovariectomies which are associated with less pain, less complications, and is a faster surgery.
Q: Can my dog develop pyometra (uterine infection) if you don’t remove the uterus?
A: Ovaries are the drivers of pyometra, not the uterus.
Uterine infections are hormonally driven processes and are an abnormal uterine response to repeated exposure of the hormone called progesterone.
If the ovaries of your dog are removed, then a pyometra can’t occur because the source of progesterone has been removed. A lap spay accomplishes this.
Q: Can my dog develop uterine cancer?
A: Uterine cancer in dogs is not common. The incidence of uterine cancer is 0.03% of all cancers found in dogs.
However, most of these uterine cancers are benign tumours and only 10% of these tumours are malignant (spread to other organs).
So overall, your dog has a 0.003% chance of developing a malignant uterine tumour.
To look at the equation on the other side, there is a much higher rate of complications, including fatal complications, from the process of removing the uterus during a spay.
Also, these cancers are thought to be hormonally-driven, so by removing the ovaries at a young age, the likelihood of developing uterine cancer is even more remote.
Other European countries have been removing the ovaries alone during spays for decades and they have not found a higher incidence of uterine cancer in these dogs.
Q: My vet told me it’s not worth it because their incisions are so small, if you add up the 2 laparoscopic incisions, they would be the same size.
A: While that may be the case, there are 4 major problems with that:
If you are trying to do surgery through a tiny hole traditionally, that means you cannot see what you are doing and blindly hooking and grabbing the organs.
Anatomically speaking, the ovaries are up at the level of the ribs and the uterine body is down by the bladder. To get everything outside of the body to do their surgery through 1 tiny hole, they really have to pull and tug on the ovaries and uterus causing soft tissue trauma and pain.
If the stitches were to come undone (your pet gets their t-shirt off and licks the stitches out), 2 separate smaller incisions are less likely to present a major complication than 1 larger one. Dogs have literally had their intestines fall out of their body after being spayed in this exact scenario. This is not possible with the incisions from a lap spay.
Small incisions are not the main benefit of the laparoscopic surgery. The pain associated with the spay is mostly derived from the traditional surgeon ripping the ovarian ligament off the body wall so they can pull out the ovary to put their sutures around it.
Q: My vet told me a high number of laparoscopic procedures get converted to a traditional open surgery, so we should just go straight for the old-style surgery and skip the risk of needing to convert.
A: The risk and rate of conversion is extremely low and a rare case.
Since we started performing laparoscopic spays in 2018, we have only needed to convert to an open procedure once due to extenuating patient circumstances.
Q: My vet told me that laparoscopic spays cannot be performed safely in small dogs
A: Most of our key-hole spay patients weigh between 8 and 10kg and we’re very happy going down as far as 3.5kg.
In fact, since our smaller patients tend to be Cockerpoos and Cavapoos, which can be very sensitive to pain, they benefit even more from a key-hole procedure than other more stoic breeds.
Q: If a laparoscopic spay is so good, why don’t all vets perform it?
A: The simple answer is cost and culture.
The equipment required costs in excess of £30,000 and not all practices have the finances or willingness to invest in this.
As an independent practice, we are not governed by a corporate board and all our profits can go into improving our practice and the service we offer rather than to banks, private equity firms and hedge funds in the City. If it means the owners only take a holiday every 2 years, that’s just the way it is.
On a cultural basis, some vets prefer to carry on using the same technique they have been performing for years, learnt in the same century when HIV and cancer was a death sentence, pregnancy scans were rarely performed, and abdominal surgery resulted a long stay in hospital.
Q: My vet is so fast and good at doing traditional spays, that the extra anaesthesia time is not worth the benefit of less pain and faster recovery.
A: Spays are the most common procedure that are performed in veterinary clinics. Most vets are very good at it. However, it doesn’t mean that it is the right way to do it.
Both human and veterinary medicine is very slow to change, even when the data clearly shows there is a better way.
Being fast at a spay doesn’t change how much it hurts.
Our total anaesthesia time is slightly longer, but this is due to setting up the sterile surgical equipment. The true surgical time from making the first incision to putting in the last stitch is actually quicker in a key-hole spay.
A small amount of extra anaesthesia time isn’t the issue; less pain creates less anaesthetic risk.
Q: Why is an old-style spay so painful?
A: The technical answer is that as we’ve said above, to pull the ovaries out of the body (essential for tying off the blood vessel properly), the ‘ovarian suspensory ligament’ has to be torn away from the inside of the abdomen.
This allows the ovaries to be mobilised to bring them out of the body. Unfortunately, the ovarian suspensory ligament attaches next to the diaphragm, the structure that moves up and down every time you breathe.
Put simply, during an old-style spay, the ovaries are ripped out of the body, tearing the inside of the abdomen in the region of the diaphragm.
This causes wholly avoidable discomfort for many days after the procedure while the tissues heal.
Every-time that patient breathes in and breathes out, the diaphragm moves and the torn tissues are traumatised further.
When a traditional spay is performed and the surgeon is ripping the ovarian ligament off the body wall, it hurts so much these patients try to wake up!
This is a very well-known fact of a traditional spay and often triggers a comment from the anaesthetist along the lines of “I know you’re pulling on the ovaries now, because she’s really feeling that!”.
To counteract that pain, the anaesthetist turns the gas anaesthesia up to get them to a deeper plane of anaesthesia.
This is the bigger anaesthetic risk, not the few extra minutes of stable anaesthesia.
Q: Are all laparoscopic spays done the same way?
A: Broadly speaking yes, although we have taken extra measures that we feel reduce the pain and complication levels even further.
We have modified a (technical!) part of the procedure to make it even more comfortable for our patients and we’re only aware of one other practice in the UK (in Kent) that does this.
Equally, last year we invested over £20,000 in a new blood vessel sealing system (Covidien ValleyLab LS10 with LigaSure handpieces); we use exactly the same system that is used world-wide in human operating theatres.
Q: Why are there fewer complications with a laparoscopic spay?
A: The Ovarian Artery is a large, high pressure blood vessel that will cause a fatal internal bleed if not properly ligated.
Unfortunately, this blood vessel also runs next to the ligament that has to be torn. All vets are taught to ‘tear the ligament but watch out for the blood vessel’.
Sadly, sometimes the artery tears as well and despite seemingly being dealt with at the time, some dogs have been examined later in their kennel with white gums and a swollen abdomen full of blood. In these cases, the vet would have to ‘go back in’ – re-anaesthestise the patient, make a much larger abdominal wound and try and locate the bleeding artery.
In addition, other smaller blood vessels run next to the ligament and are torn routinely as part of the old-style spay procedure. These normally bleed at a low-level giving rise to the ‘blood ooze’ that an old-style spay generates.
Reassuringly, in a key-hole procedure, all vessels are sealed and cut without any tension, nor any tearing. We only put one small surgical swab in our lap-spay surgical packs and even this is only used for swabbing bleeding generated from the initial skin incisions.
We would estimate the volume of blood-loss in an average key-hole spay to less than half a tea-spoon – less than you would sustain from a minor cut to a finger.
Q: Isn’t it dangerous putting long metal instruments into the body?
A: We use human-grade surgical cameras and instruments made by Olympus and Karl Storz.
Both companies have been making surgical equipment for human operating theatres for decades and are the leading manufacturers world-wide.
We sterilise all our equipment using Ethylene Oxide gas and whilst expensive, this gives us complete security in knowing that anything we put into the body is sterile and safe.
Our hands never enter the body cavity in a key-hole spay.
Using sterile, smooth, safe metal and plastic equipment is much better tolerated by the body than the powder, latex and potentially bacteria transferred from a surgeon’s gloved hands.
Put simply, a gloved hand delving into the abdomen is far more likely to trigger inflammation and infection.
Q: Is it really worth the extra money?
A: That’s a question that only our clients can answer (!) although we firmly believe it is. We don’t feel that it’s possible to put a price on the benefits that a key-hole spay brings.
We think it’s worth asking the question: “would you pay extra to have at least 10 days of massively reduced pain and surgical complications?”.
Since offering key-hole spays, only two owners have asked for old-style spays due to cost.
The pain associated with the outdated spay is mostly derived from the traditional surgeon ripping the ovarian ligament off the body wall so they can exteriorize the ovary to put their sutures around it.
The advantage of a key-hole spay is less pain, faster recovery times and fewer complications.
In human surgery in the early 1980s, key-hole surgeons were seen as mavericks, performing new and dangerous surgery. Performing a key-hole procedure ran the risk of investigation by the General Medical Council (GMC).
A decade later, in the 1990s, not performing a key-hole procedure ran the risk of investigation by the GMC.